Pain and Fear

Causes of psychophysiologic disorder (PPD) symptoms are so diverse that even after assessing thousands of patients I still encounter new variations. Earlier this year a 65 year old retired nurse practitioner from Oregon whom I have worked with in the past contacted me because of months of abdominal pain. She suspected PPD because medical evaluation was unrevealing and her symptoms fluctuated for no obvious reason.

The pain began immediately following a visit with her 85 year old mother who is frail and resides in a nursing home. Her mother has always been a difficult person, often verbally abusive. The patient’s two brothers as well as all other family members refuse to see her. The visit was, as usual, not a pleasant one but no worse than many other such encounters. However, she decided to stop the visits and only contact her by phone in future. Unexpectedly, the patient became very emotional in discussing this. Why?

As she thought about this, she recalled the visit with her mother was the first following her recovery from a “lumpectomy” for breast cancer. She was advised that her chance for full recovery was excellent but the experience was a definite reminder of her mortality. Visiting her frail mother was another reminder and the combination was, evidently, emotionally powerful. But was that enough to move her to tears months after the event and also cause significant pain? I suspected there was more to the story.

Many of my patients have high levels of anger at a parent of which they are not fully conscious. This anger can be expressed via the body (in the form of symptoms) when there is no verbal outlet. But my former colleague was aware of her resentment towards her mother and had been for decades. She had no difficulty venting these feelings with one of her sympathetic brothers.

Other patients spend much of their childhood trying in vain to meet the needs of a parent who seems never to be satisfied. As adults, these individuals may lack the self-care skills they need to give themselves a break. Stress levels often reach the point of causing physical illness. Though my colleague admitted to providing considerable support to her partner and her grandchildren, she had learned over the years to carve out regular time for putting herself on the list of people for whom she cares.

So I returned to the issue that first brought her to tears and asked if there were any other reasons why confronting her mortality might be particularly difficult. It was then she recognized that mortality was not the issue, rather it was fear of being abandoned late in life, with her mother being the prime example. She couldn’t shake the image of herself finishing life bereft of loved ones and tears flowed again as she spoke.

Unrecognized negative emotions are common causes of PPD but I had never encountered this particular fear in another patient. It took me awhile to devise a treatment plan. I began with the idea that what we give of ourselves to others has a way of being returned. My favorite example is the film “It’s a Wonderful Life”, recognizing that is a somewhat over-the-top ideal. Then I asked her to recall the time she spends providing support to her partner, her children and her school-age grandchildren. Finally, I asked her to imagine her mother being with the grandchildren while she looked on as a fly on the wall. “What would it be like to watch your mother interact with those kids? Would there not be a dramatic difference compared to how you behave with them?,” I wanted to know.

The thought experiment of imagining her mother with her grandchildren highlighted the night and day difference in affection and support provided by my patient compared to what her mother would provide. This was the strongest assurance I could find that in my patient’s declining years the love and support would be returned. With this thought percolating, I am optimistic her symptoms will improve soon.